Histologic deterioration and more flares: The case against azathioprine plus methylprednisolone in the treatment of proliferative lupus nephritis

✍ Scribed by Tak Mao Chan

• Publisher: John Wiley and Sons
• Year: 2007
• Tongue: English
• Weight: 40 KB
• Volume: 56
• Category: Article
• ISSN: 0004-3591
• DOI: 10.1002/art.22448

✦ Synopsis

An ideal immunosuppressive treatment for severe lupus nephritis should be devoid of adverse effects but potent enough to abate the inflammatory process rapidly. Corticosteroid combined with cyclophosphamide (CYC) has been the conventional treatment, although the side effects of CYC are well recognized. In this issue of Arthritis & Rheumatism, Grootscholten et al (1) report that an immunosuppressive regimen comprising methylprednisolone (MP) (9 intravenous 1-gm pulses in 2 months)/prednisone (20 mg/day tapered to 10 mg/day over 5 months) and azathioprine (AZA) (2 mg/kg/day) given for 2 years was associated with more progression of chronic renal histopathologic lesions compared with prednisone (1 mg/ kg/day for 4 weeks tapered to 10 mg/day after 6 months) and CYC (6 intravenous 750-mg/m 2 pulses given at 4-week intervals followed by 7 pulses given at 12-week intervals) (2). These conclusions were based on findings in 39 pairs of renal biopsy samples, obtained at baseline and after 2 years of treatment. In another report from the same study it was noted that, while high response rates (ϳ90%) were achieved with both treatment regimens, relapses were more frequent in the AZA plus MP group (2).

In the pathologic study (1), 10.3% of patients showed doubling of the baseline serum creatinine level at the last followup (median followup 77 months), and the AZA plus MP regimen was associated with a 5.2-fold increase in risk of this outcome compared with the CYC regimen. Thus, there was concordance between renal function and histologic end points.

It is pertinent to note that the study by Grootscholten and colleagues (1) compared 2 immuno-